3344 Fourth Avenue, Suite 100, San Diego, CA 92103

Jodi Staszak, M.F.T

Licensed Marriage and Family Therapist M.F.T. #MFC52048

3344 Fourth Avenue, Suite 100, San Diego, CA 92103

(619) 818-0375 Email:

INFORMED CONSENT

Welcome to my office. As a licensed Marriage and Family Therapist, I am governed by certain laws and regulations and by the code of ethics for my profession. The ethics code requires that I make you aware of certain office policies which may affect you. Please take the time to read the following information.

Your Rights as a Client

You have the right to ask questions about any procedures used during therapy. You have the right to decide at anytime not to receive therapy from Jodi Staszak. If you wish, she will provide you with the names of other qualified professionals whose services you might prefer. You have the right to end therapy at any time without any moral, legal or financial obligations other than those already accrued.

Confidentiality

Within certain limits, information revealed by you during therapy will be kept strictly confidential and will not be revealed to any other person or agency without your permission. At times, therapy will involve the participation of more than one family member and/or other significant person(s). While your therapist will attempt to follow your wishes, she does not guarantee confidentiality among participants within the family or couples therapy.

There are certain situations in which your therapist is required by law to reveal information obtained during therapy to other persons or agencies without your permission. These situations include:

If you threaten bodily harm or death to another person, your therapist is required by law to inform the intended victim and appropriate law enforcement agencies.

If you threaten bodily harm or death to yourself, your therapist may inform the appropriate law enforcement agencies and others (such as a spouse, friend, or an inpatient psychiatric institution) who could aid in prohibiting you from carrying out your threats.

If you reveal information related to the abuse or neglect of a child, dependent adult, or elderly person, your therapist is required by law to report this to the appropriate authorities.

Other Exceptions to Confidentiality

Some exceptions to confidentiality include billing account management, managed care, worker’s compensation claims, and disclosure to insurance and collection agencies. Please be aware that many companies require private information about you, such as diagnosis, symptoms, treatment and response to treatment in terms of billing health insurance. This carries a certain amount of risk to privacy and to future capacity to obtain health or life insurance. Please refer to the Federal Health Insurance Portability and Accountability Act (HIPAA) form regarding the use and disclosure of you Protected Health Information (PHI).

Another exception to confidentiality is if you are involved in a litigation process. If your records are ever requested by the court, you will be notified, and your therapist will claim privilege on your behalf. Only the essential information will be disclosed. It is important to know that if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain your therapy records, and/or your therapist’s testimony.

Risks and Benefits of Therapy

Psychotherapy is a process in which a therapist and patient discuss a myriad of issues, events, experiences and memories for the purpose of creating positive change so the patient can experience his/her life more fully. It provides an opportunity to better, and more deeply understand oneself, as well as, any problems or difficulties that the patient may be experiencing. Psychotherapy is a joint effort between a patient and a therapist. Progress and success may vary depending upon the particular problems or issues being addressed, as well as on many other factors.

Participating in therapy may result in a number of benefits to the patient, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may also require substantial effort on the part of the patient, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors. There is no guarantee that therapy will yield any or all of the benefits listed above.

Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. There may be times in which the therapist will challenge the patient’s perceptions and assumptions, and offer different perspectives. The issues presented by the patient may result in unintended outcomes, including changes in personal relationships. The patient should be aware that any decision on the status of his/her personal relationships is the responsibility of the patient.

During the therapeutic process, many patients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating. The patient should address any concerns he/she has regarding his/her progress in therapy with the therapist.

Patient Litigation

The therapist will not voluntarily participate in any litigation, or custody dispute in which the patient and another individual, or entity, are parties. Thetherapist has a policy of not communicating with the patient’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in the patient’s legal matter unless you release the information by authorizing a release/exchange of confidential information. Thetherapist will generally not provide records or testimony unless compelled to do so.

Records and Record Keeping

The therapist may take notes during session, and will also produce other notes and records regarding the patient’s treatment. These notes constitute the therapist’s clinical and business records, which by law, the therapist is required to maintain. Such records are the sole property of the therapist. The therapist will not alter his/her normal record keeping process at the request of any patient. Should the patient request a copy of the therapist’s records, such a request must be made in writing. The therapist reserves the right, under California law, to provide the patient with a treatment summary in lieu of actual records. The therapist also reserves the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider.

Psychotherapist-Patient Privilege

The information disclosed by the patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between the therapist and the patient in the eyes of the law. Typically, the patient is the holder of the psychotherapist-patient privilege. If the therapist received a subpoena for records, deposition testimony, or testimony in a court of law, the therapist will assert the psychotherapist-patient privilege on the patient’s behalf until instructed, in writing, to do otherwise by the patient or the patient’s representative. The patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. The patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney.

Therapist Availability and Contact Information

Electronic Communications: Jodi Staszak cannot ensure the confidentiality of any form of communication through electronic media, including text messages. You are also advised that any email sent to her via computer in a work-place environment is legally accessible by an employer. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, she will do so. Please do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Jodi Staszak’s office is equipped with voice mail that allows you to leave a message at any time. She will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. She is unable to provide 24-hour crisis service. If you have a counseling emergency, please call the 24 hour Emergency Crisis Line at 1-888-724-7240, dial 911, or go to the nearest emergency room.

Jodi can be reached at (619) 818-0375. You may email her at f for non-emergencies only such as appointment changes, referrals and non-clinical questions. She checks her emails as often as possible, but if you are cancelling an appointment with less than 24 hours notice, please call her voicemail and note that there will be a $50 cancellation fee for any cancellation with less than 24 hour notice.

Friending: Jodi Staszak does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). Adding current or former clients as friends or contacts on these sites can compromise confidentiality and respective privacy. It may also blur the boundaries of the therapeutic relationship. If you have questions about this, please bring them up with Jodi when you meet so you can talk more about it. .

Termination of Therapy

The therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, the patient needs are outside of the therapist’s scope of competence or practice, or the patient is not making adequate progress in therapy. The patient has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate therapy, the therapist will generally recommend that the patient participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. The therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to the patient.

Financial Matters

Jodi Staszak’s fee is $140 per 50 minute session. Jodi doesdedicate a portion of her private practice to working with people who are undergoing financial hardships or are of a lower income and has a limited number of subsidized slots available. Your counseling fee is $______per counseling session based on a sliding fee scale. For all fee for service clients,payments arecollected directly from clients. Itemized forms may beprovided (including typeof service and diagnosis code as well as any other information needed) that clients can submit to their insurance company for reimbursement.
Jodi Staszakisnow accepting Blue Shield PPO andAetna insurance only, however many people find that other insurance providers may pays for a portion of their therapy. To find out what your insurance company will cover, call your insurance company and ask if they cover the services of “out of network” licensed marriage and family therapists (MFTs). If your insurance is denied for any reason you will be responsible for this therapist’s hourly rate. This fee includes additional time for administrative duties, note taking and planning. The appointment time is reserved exclusively for you. Thus, you are responsible for providing 24 hours advance notice if you cancel an appointment to avoid a cancellation fee. If less than 24 hours notice is provided, a cancellation fee of $50 will be incurred by you. Initials ______Initials______

The undersigned, by providing his/her signature in the space below agrees to accept the therapy services provided by Jodi Staszak, MFT in accordance with, and pursuant to the terms and conditions set forth herein.

SIGNATURE:

PATIENT NAME:

SIGNATURE:

PATIENT NAME:

DATE: ______

Licensed Marriage and Family Therapist M.F.T. #MFC52048